COMPANY OVERVIEWTriWest Healthcare Alliance, headquartered in Phoenix, Arizona, manages and administers quality healthcare services for our nation's active and retired uniformed military service members and their families, through a contract with the Department of Defense.These individuals are eligible for the DoD's regionally managed health care program for the military, called TRICARE. TriWest manages and administers TRICARE throughout the 21-state TRICARE West Region.In addition to supporting military families through the TRICARE program, TriWest has developed relationships with organizations such as the USO, Fisher House, the Women in Military Service for America Memorial Foundation and other military relief and support associations to strengthen America's military community locally and nationally.TriWest provides state-of-the-art facilities, a smoke/tobacco-free, drug-free, business casual working environment, and offers a competitive compensation package including excellent benefits.For more information about TriWest, please explore our website at www.triwest.com.DOD STATEMENTYou are applying for a position that involves working on electronic systems that have access to Department of Defense ('DoD') systems. Therefore, you must undergo a DoD background investigation. This requires you to submit an application describing the previous 7 years of your life and to provide proof of U.S. citizenship in the form of a certified birth certificate, certificate of naturalization, current passport, form FS-240 or form DS-1350. This process takes several months to complete. During this time, the DoD will grant interim access to U.S. citizens allowing them to work for TriWest until their background investigation is completed. However, the DoD will not authorize interim access for non-U.S. citizens. If you are unable to obtain interim access or pass the background investigation, you are not qualified for this position and TriWest will withdraw any offer of employment or terminate your employment immediately.JOB SUMMARY/DESCRIPTIONUnder direct supervision of the Director, Program Integrity, incumbent, utilizing extensive data management, investigative, and analytical expertise, will directly supervise all FAMS Super Users in planning and developing detailed provider models and profiles, and will provide department oversight and analysis of system reports and data from FAMS, DB2, Forest and Trees and other data query systems. Incumbent will supervise, guide and direct FAMS Super User subordinates, as well as Program Integrity analysts and Clinical Specialists in the use and documentation of data from the complex, technical, and sensitive software applications (FAMS, Oracle, Cognos, FACTS, DB2/SQL, CRMS, and Forest and Trees) utilized by the Program Integrity Department. Incumbent will supervise the identification, investigation, analysis, and report preparation of any suspected healthcare fraud and/or abuse issues as defined by TRICARE; and provide specific FAMS training for subcontractors and TriWest employees on fraud and abuse issues. Incumbent will be responsible for preparing accurate, complete and timely monthly, quarterly, semi annual and annual Program Integrity reports as required by TRICARE Management Activity.Key Responsibility Areas:o Supervises data mining and reporting systems utilized by the Program Integrity department:o Creates or oversees the development of complex provider models. Produces provider profiles from the FAMS system, maintains support files, creates SLE files and runs specialty reports (Feature Value Generation), applying extensive data and analytical expertise.o Assesses data output and develops appropriate recommendations for next direction.o Trains staff on data visualization, cluster, and profile data analysis to identify outliers. Verifies the FAMS data by comparison with DB2 Oracle reports and/or claims processing in Forest and Trees.o Orients and trains new FAMS users, instructing them on data visualization, Cognos reporting features, and users guide. Trains new users in PI case tracking system.o Trains staff on FAMS enhancements and new features following software upgrades and provides written reference tools for users.o Performs FAMS and FACTS user maintenance and initial troubleshooting of usage issues and other system issues. Functions as Point-of-Contact for and maintains a liaison with IBM technical support for in-depth problem solving. Collaborates with the IT staff on system maintenance and/or downtimes related to FAMS.o Performs DB2 Oracle queries and provides report data within timelines.o Prepares case packages on outliers, including findings summaries and supporting reports for future investigation.o Interprets TRICARE and Medicare coverage guidelines, policies, and procedures.o Proactively supervises data mining to identify, investigate, and research potential fraud and abuse issues.o Supervise data mining efforts regarding TMA directed investigations and data collection for fraud and abuse cases.o Utilizes appropriate data systems and artificial intelligence to research, document, and track fraud and abuse issues and activities.o Develops reports to meet TRICARE reporting requirements and regular management reports on department outcomes.o Takes active steps to expand knowledge of FAMS by attending user group meetings.o Maintains the confidentiality and non-discoverability of all fraud and abuse, quality assurance and risk management issues.o Perform other duties as assigned.Working Conditions:o Availability to work any shifto Works in a standard office environment, with minimal travelo Extensive computer work with prolonged sittingo Department of Defense security clearance requiredQUALIFICATIONSRequiredo 2 years college courseworko Demonstrated proficient in data analysis, CRMS, and on-line systems (DB2/SQL and Forest and Trees)o Demonstrated proficient with Word, Excel, Access and Outlooko Expertise with training curriculum development, assessment evaluations, and writingo 4 years FAMS utilization experience in data mining, profile design, healthcare fraud and abuse identification and report preparation and interpretationo 3 years data mining systems and/or general supervisory experienceo 3 years experience with statistical analysiso 2 years experience in claims processing or quality assurance capacityo Knowledge of quality review and claims analysis techniqueso Focused, flexible, and detail-oriented with eye for accuracyo Detailed knowledge of healthcare fraud and abuse types processes and activitiesKnowledge& Skills:Technical Skills: Knowledge of data analysis, statistical quality control, and performance metrics; Proficient with Word, Excel, and Access; Strong writing skills and reporting; Working knowledge of claims processing operations, claims analysis, utilization review techniques and processes, quality assurance, and quality management techniques and processes; Familiarity with the CMS1500 and UB-92 forms.Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; Has a realistic understanding of relevant issuesInformation Management: Ability to manage large amounts of complex information easily, communicate it clearly, and draw sound conclusionsCommunication/People Skills: Ability to influence or persuade others under positive or negative circumstances; Adapt to different styles; Listen critically; CollaborateTeam-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitmentCoaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedbackMulti-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environmentOrganizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; Detail-orientedComputer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applicationsBENEFITSTriWest offers a comprehensive and progressive benefits package that includes:o Medical, dental and vision coverageo Generous paid time offo 401(k) Retirement Savings Plan (with matching)o Short-term and long-term disability, basic life, and accidental death and dismemberment insuranceo Voluntary plans such as pet insurance, long-term care and 529 College Savings Planso Reimbursement for various wellness initiativeso Tuition reimbursementEQUAL EMPLOYMENT OPPORTUNITYTriWest Healthcare Alliance is an equal employment opportunity employer. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.JOB CATEGORY-CAREERBUILDERJN023